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STATE OF CALIFORN1d WATER RESOURCES CONT1I11mI[BOARD <br /> FORMA': UNDERGROUND STORAGE TANK PROGRAM o Z <br /> SITE //�� � FACILITY/SITE, INFORMATION and/or PERMIT APPLICATION <br /> LY a <br /> COMPLETE THIS FORM FOR EACH FACILITY/SITE <br /> MARK ONLY ❑ 1 NEW PERMIT 3 RENEWAL PERMIT 5 CHANGE OF INFORMATION ❑ 7 PERMANENTLY CLOSED SITE <br /> ONE ITEM ❑ 2 INTERIM PERMIT ❑ 4 AMENDED PERMIT 6 TEMPORARY SITE CLOSUREqp <br /> i u <br /> 1. FACILITY/SITE INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> FACILITY/SITE NAME JC� CARE OF ADDRESS INFORMATION <br /> I <br /> ADDRESS NEAREST CROSS STREET ✓BWbo6El OWMT [I PARTNERSHIP ❑ FEDSL GENU'STATE <br /> CITY NAME STATE ZIP CODE SITE PHONE k,WITH AREA CODE <br /> CA <br /> TYPE OF BUSINESS: ❑ 2 DISTRIBUTOR ❑ <PROCESSOR ✓Bax it INDIAN EPA ID N N of TANK'S <br /> ❑ 1 GAS STATION 3 FARM ❑5 OTHER TRUST LANDS or El RESERVATION AT THIS SITE <br /> EMERGENCY CONTACT PERSON(PRIMARY) EMERGENCY CONTACT PERSON(SECONDARY) <br /> DAYS: NAME(UST.FIRST) PHONE N WITH AREA CODE DAYS. NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE NIGHTS: NAME(LAST,FIRST) PHONE N WITH AREA CODE <br /> 11. PROPERTY OWNER INFORMATION &ADDRESS— (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa to indicate ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIPCODE PHONE N,WITH AREA CODE <br /> Ill. TANK OWNER INFORMATION & ADDRESS — (MUST BE COMPLETED) <br /> NAME CARE OF ADDRESS INFORMATION <br /> MAILING or STREET ADDRESS ✓Boa toindicale ❑ PARTNERSHIP ❑ STATE-AGENCY <br /> ❑ CORPORATION ❑ LOCAL-AGENCY ❑ FEDERAL-AGENCY <br /> ❑ INDIVIDUAL ❑ COUNTY-AGENCY <br /> CITY NAME STATE ZIP CODE PHONE N,WITH AREA CODE <br /> IV. LEGAL NOTIFICATION AND BILLING ADDRESS <br /> CHECK ONE(1)BOX INDICATING WHICH ABOVE ADDRESS SHOULD BE USED FOR BOTH LEGAL NOTIFICATION AND BILLING: L ❑ II- ❑ III-❑ <br /> THIS FORM HAS BEEN COMPLETED UNDER PENALTY OF PERJURY,AND TO THE BEST OF MY KNOWLEDGE,IS TRUE AND CORRECT. <br /> APPLICANT'S NAME(PRINTED&SIGNATURE) DATE <br /> LOCAL AGENCY USE ONLY <br /> COUNTY N JURISDICTION N AGENCY N FACILITY ID N N of TANKS N SITE <br /> E= = = <br /> CURRENT LOCAL AGENCY FACILITY IDN APPROVED BY NAME PHONE N WITH AREA CODE <br /> C <br /> PERMIT NUMBER PERMIT APPROVAL DATE PERMIT EXPIRATION GATE <br /> EL <br /> CENSUS TRACT SUPERVISOR-DISTRICT CODE BUSINESS PLAN FILED DATE FILED <br /> / YES NOPERMIT AMOUNT SURCHARGE AMOUNT FEE CODE RECEIPT N B <br /> THIS FORM MUST BE ACCOMPANIED BY AT LEAST(1)OR MORE TANK PERMIT FORM 'B'APPLICATION(S), UNLESS THIS IS A CHANGE OF SITE INFORMATION ONLY. <br /> FORM A(3-2-68) «. _ <br /> DATA PROCESSING COPY / / <br />